Provider Demographics
NPI:1093228157
Name:PINE RIDGE INDIAN HEALTH SERVICE
Entity Type:Organization
Organization Name:PINE RIDGE INDIAN HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-867-3040
Mailing Address - Street 1:PO BOX 1201
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-1201
Mailing Address - Country:US
Mailing Address - Phone:605-867-3032
Mailing Address - Fax:
Practice Address - Street 1:EAST HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-867-3032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
HSZ153OtherMEDICARE PART B